On Cholera Worldwide

November 1, 2010

Though the last major outbreak in the United States occurred in 1911, cholera remains a persistent health concern in many parts of the world, including Asia, the Middle East, Latin America, and sub-Saharan Africa. Recent outbreaks have been seen in Nigeria,  where cholera has killed more than 1,500 people this year, and in Haiti, where survivors of the massive January earthquake have been affected by an outbreak that has infected an estimated 2,300 people and killed at least 200. Due to cholera, there are an estimated three to five million new cases reported worldwide and between 100,000 and 120,000 deaths each year. Like other diarrheal illnesses, cholera is easily treatable and can be prevented through the provision of safe water, improved sanitation services, and education about the importance of hygiene.

Cholera

Cholera is an acute diarrheal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. Though three-quarters of individuals infected with V. cholerae do not exhibit any symptoms, they may shed the bacteria in their stool for seven to 14 days, potentially infecting others. While V. cholerae is the direct source of cholera infection, the deadly effects of the disease are caused by a toxin called CTX, that the bacteria produce in the small intestine of the host. CTX binds to the intestinal walls and interferes with the normal flow of sodium and chloride, causing the body to secrete large amounts of water and leading to diarrhea accompanied by dehydration. In individuals exhibiting the severe form of the disease, the rapid loss of fluids can lead to dehydration and shock, and without treatment death can occur within hours. Approximately one in 20 individuals infected with the bacteria develops symptoms associated with cholera, which include: severe, watery diarrhea; nausea and vomiting; muscle cramps; dehydration; and shock.

The rapid loss of fluids in a short period of time – often as much as a quart in an hour – associated with diarrhea due to cholera, makes the disease particularly deadly. In order to replenish the fluids and electrolytes that an individual with severe cholera has lost, Oral Rehydration Salts (ORS) must be administered. If a pre-formulated solution is not available, experts suggest combining one-half teaspoon salt, one-half teaspoon baking soda, and three tablespoons sugar in one liter of safe drinking water. With the prompt delivery of ORS, up to 80 percent of people can be treated successfully, with a fatality rate below one percent. Antibiotics may be used in conjunction with ORS to shorten the course and lessen the severity of the illness, however their delivery is less critical to cholera patients than rehydration. To help control the spread of the disease, two types of oral cholera vaccines are also available, but according to experts they provide only a short-term effect and should be administered in areas where ongoing water and sanitation improvement programs are in place.

Despite the simplicity of the cure, thousands of people die each year in regions that lack effective sanitation and water purification systems. Following man-made or natural disasters, the risk of an initial outbreak of cholera growing into an epidemic is greatly increased. As seen recently following floods in Pakistan and Nigeria, the spread of cholera becomes a major public health concern when there is a lack of clean water. By providing treatment as well as information about the importance of boiling water before drinking and maintaining personal hygiene, it may be possible to slow or even stop the spread of cholera and other communicable diseases.

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Call for Mobility Aid Donated Goods for Haiti Relief

March 2, 2010

iCons in Medicine, under the auspices of its parent company the Center for International Rehabilitation, is seeking donations of Mobility Aids to support ongoing rehabilitation relief efforts in Haiti.

Needed items include Adult and Pediatric Crutches, Walkers, and Wheelchairs

Crutches, Walkers, and Wheelchairs

Details on Criteria for Mobility Aid Donation

Mobility aid donations can be made by individuals, as well as bulk product donations by manufacturers and distributors. Monetary donations for purchase of mobility aids may also be made. For complete instructions, please click the appropriate link below:

Individuals Making Mobility Aid DonationsManufacturers or Distributors Making Bulk Product DonationsMaking a Monetary Donation for the Purchase of Mobility Aids

There are a number of other ways you can help provide support to medical and rehabilitation efforts through iCons in Medicine.

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Amputation and Prostheses in Haiti

February 8, 2010

As government agencies and non-governmental organizations flood Haiti to provide relief support, many are finding a lack of even the most basic medical equipment and supplies. Even before January 12th, Haiti’s healthcare system was unable to fully support the needs of the Haitian population which included 800,000 individuals with disabilities, and life-saving medications were in short supply but high demand. While outbreaks of tuberculosis, HIV, and cholera are the current major public health concerns, insuring the provision of rehabilitation services to the estimated 200,000 (some reports indicate 250,000) individuals who have undergone amputations as a result of the earthquake are especially pressing. This figure includes not only the 2-3,000 individuals who have had amputations of major bones as well as the thousands more who have fingers or toes amputated (per personal correspondence with Al Ingersoll, CP; Healing Hands for Haiti).

Without proper medical equipment and often in unsterile conditions, physicians providing care in Haiti since the earthquake struck have had to amputate the limbs of individuals who otherwise would die. The social stigma attached to individuals with disabilities in Haiti and other developing nations has led some Haitians to leave gangrene infections untreated, as they would rather die that face the prospect of living without an arm or leg. In addition to possible infection at wound sites, individuals who have suffered “crush injuries” or rhabdomyolysis are at risk developing kidney failure when the crushed muscle ruptures. Studies indicate that between four and 33 percent of patients with rhabdomyolysis develop kidney failure, but amputation of the affected limb has the potential to save the patient’s life. In order to perform these amputations, CNN reports that some surgeons have had to use “civil war medicine” – amputating limbs with saws and other instruments, often without anesthesia. Some estimates indicate that as many as 95 percent of Haitians who suffered crushing injuries in the earthquake will undergo amputation.

Haiti’s hospitals sustained considerable damage and what remains of the Haitian healthcare system has been overwhelmed by the demand of those in need of medical services. To fill this gap, clinics run both by local hospital staff and international aid organizations have been setup in tents outside the devastated buildings. Reports indicate that surgeons at University Hospital, Port-au-Prince’s largest hospital, performed approximately 225 amputations within the first few days following the earthquake. Though statistics are not available yet for the number of new amputees, Mirta Roses, director of the Pan American Health Organization, has indicated that some hospitals have reported performing as many as 30 amputation surgeries per day. Limitations of space, medical personnel, and other resources have forced many makeshift Haitian surgical wards to discharge individuals after amputations are completed, overloading what remains intact of Haiti’s fragile hospital system with patients in need of post-operative care. To assist further assist these individuals, organizations like Healing Hands for Haiti, Handicapped International, and Doctors Without Borders are making efforts to provide surgical and post-operative care following amputation. Additionally, Global Relief Technologies has introduced a system that allows for critical information about patients to be collected and uploaded to a PDA so that this information can be shared with other aid organizations to ensure high-quality care for all amputees.

In addition to the importance of post-operative care, individuals who have undergone amputation are in need of prostheses, but the devices commonly used in the developed world may not be best suited for use in Haiti. An average prosthesis can cost between $4,000 to $6,000 and in the United States a new amputee could expect to undergo a minimum of four fittings a year for the life of the prosthesis to ensure that the device is comfortable – in Haiti this is simply outside the realm of possibilities. Low-cost, high-quality devices developed by non-profit organizations, including the Center for International Rehabilitation (CIR) and Legs for All may be applicable for use in Haiti. Developed specifically for use in areas with limited resources, the Center for International Rehabilitation’s CIR Casting System could allow for the rapid fitting of Haitian amputees. Unlike traditional plaster-based prosthetic fabrication methods, the CIR Casting System uses a fabric bag filled with polystyrene beads and allows for the fabrication of prostheses in a fast, simple, and low-cost manner. A final prosthesis can be fabricated in less than two hours during a single clinical visit, compared with at least two clinical visits using traditional plaster-based methods. In addition to the development of this innovative fabrication method, the CIR conducts blended distance learning initiatives that combine online training with hands-on workshops to familiarize local technicians with the fabrication method. Since 2008, following trainings in Thailand and India, over 2,500 individuals have been fitted using the system and it has been widely accepted in these regions. However, as Jeffrey Bigelow, resident neurologist at Yale University who completed a survey of the needs of Haitian amputees for Healing Hands for Haiti in 2004, notes,  it is important to recognize that even when using this type of appropriate technology, “devices need to be skillfully made or they’re just too painful to wear.”

Dr. Steven R. Flanagan, medical director of the Rusk Institute of Rehabilitation Medicine at NYU Langone Medical Center, noted that even in the best of circumstances, when an amputation site can be properly cared for, it can take four to six months for a traumatic amputation to heal completely. Even before they can be fitted, many of Haiti’s new amputees will require counseling to come to terms with their new lives as a part of Haiti’s generation of amputees.

Specialty physicians who wish to offer teleconsultation support to disaster-relief workers in Haiti, Health professionals who wish to provide volunteer support on the ground in Haiti, and U.S. healthcare institutions that are willing to provide services to victims of the earthquake who are airlifted to this country for urgent medical or rehabilitation care can register through iCons in Medicine.

Find out more about The Center for International Rehabilitation and the CIR’s innovative prosthetic technologies


Helping Haiti

January 25, 2010

As the devastation of the 7.0-magnitude earthquake that hit Haiti on January 12th continues to unfold, public and mental health experts are likely to be at the fore of those monitoring the situation. In addition to the immediate needs of survivor rescue, survivors of earthquakes and other natural disasters are at risk of malnutrition, parasite infection, and post-traumatic stress disorder and depression. While it is important to ensure that emergency medical care is delivered to those in need, it is also critical that a plan be put in place to ensure that infection and stress disorders are recognized and treated efficiently.

Time magazine reports that before the earthquake, Haiti was one of the poorest countries in the world. No Haitian city had a public sewage system, less than half of the population had access to drinking-water services, and malnutrition and disease affected a large portion of the population. According to CNN, the Red Cross has estimated three million people – one-third of the total population of Haiti – are affected by the earthquake. Many of those not among the reported 200,000 who lost their lives were seriously injured and will likely require amputations or other surgeries. As time passes, these acute health problems will be replaced by chronic heath conditions that may worsen quickly if individuals are not receiving treatment.

According to Columbia University public health expert, Josh Ruxin “The number one risk [following a natural disaster] is always bacterial infections where they have open wounds.” Without antibiotics and proper treatment, wounds can become infected and put individual’s health at risk. Though some were not physically harmed by the earthquake, reports indicate that 40,000 were left homeless and forced to “cluster together in public places without food, clean water or sanitation.” For individuals displaced by earthquakes or other catastrophic situations, the risk of contracting diseases or developing parasitic infections is increased. Water supplies can become contaminated quickly in refugee camps or settings with damaged potable water distribution systems, leading to a rapid spread of water-borne illnesses such as cholera and dysentery as well as diarrhea, malaria, and measles.

Some experts note that not all of the harm of this disaster will be physical. Dr. Daniella David, professor of clinical psychiatry at the University of Miami’s Miller School of Medicine, explains that “Once the initial resources are in…is when the psychological aftereffects are going to hit people.” Further, she explains, there is a normal and immediate stress response that accompanies a devastating effect that causes damage to homes and loss of friends and family members. According to Sandro Galea, chair of the Department of Epidemiology and Columbia University’s Mailman School of Public Health in New York City, acute stress, post-traumatic stress, and depression will likely be seen in Haiti at three to four times higher than baseline in the coming months. Symptoms of post-traumatic stress disorder (PTSD), including depression, anxiety, emotional numbing, and sleep disorders, are usually seen within three months of the incident, according to the Canadian Mental Health Association. According to experts, assistance for potential sufferers of PTSD – often called “psychological first aid” – includes making individuals aware of what signs and symptoms to watch for, and letting them know that their feelings are normal and that help is available. While reporting of PTSD and other psychological disturbances is frequently a concern due to the social stigma attached to mental illness, Haitian-born psychologist Marie Guerda Nicolas of the University of Miami indicates that Haitians tend to be expressive of their grief and psychological distress. Further, members of rescue teams from other nations at as great a risk, if not an increased risk, of developing PTSD or psychological trauma.

Though a global humanitarian response is currently underway, aid organizations face a daunting task as they attempt to coordinate vast amounts of aid relief and get it to individuals who require it urgently. It remains to be seen exactly how many were affected by the earthquake and if assistance can be delivered effectively to them, but the impact of the earthquake on Haiti and its people is likely to continue after the initial wounds have healed.

Specialty physicians who wish to offer teleconsultation support to disaster-relief workers in Haiti, health professionals who wish to provide volunteer support on the ground in Haiti, and U.S. healthcare institutions that are willing to provide services to victims of the earthquake who are airlifted to this country for urgent medical or rehabilitation care can register through iCons in Medicine